Home Client Contact and Insurance Verification

Client Contact and Insurance Verification

Client Contact and Insurance Verification

Please complete this form at least 24hrs prior to scheduled appointment to allow sufficient time for a benefit inquiry.

Select Therapist

Client Name*

Client Address*





Client Phone Number*

Client Email*

Client Status*

Emergency Contact Person

Emergency Contact Number

Type of Health Insurance*

Insurance Provider

Insurance Contact Number (listed on back of insurance card)

Member ID Number*

Group ID Number*

Client Date of Birth*

Subscriber Name (if different from client)

Subscriber Date of Birth (if applicable)

Deductible Amount (if known)

Co-Pay/Coinsurance Amount (if known)

 

Click on the icon below to make a secured online payment

paypal

Full fee is $125 to $175 per session. Sliding scale options are available. Most Open Avenue Therapists take insurance. Contact for details.

Note: Cancellation policy is 24 hours in advance to void responsibility for payment.